Tuesday, December 9, 2014

If Guns Threaten Health Like Smoking Or HIV, What Should Doctors Do?

The idea that guns are dangerous to your health is not new. But it is arguably as explosive as it was in 1985, when the Institute of Medicine first made the link between guns and health.

Pediatricians have established guidelines for asking parents: Do you have guns in the home, and if so, are they locked and out of reach of children?

Some physicians and gun rights groups that oppose such questions have pushed back and say they have momentum. In July, an appeals court ruled in favor of a 2011 Florida law, nicknamed Docs v. Glocks. It bans doctors from asking their patients questions about gun ownership unless the question is deemed medically necessary. Montana and Missouri have passed similar laws.

Ray Duggan, 32, a former Young Bloods gang member from Providence, told physicians at the conference about the 2004 shooting that left him paralyzed, and his work now to break up gang feuds and street violence. (Martha Bebinger/WBUR)“If people don’t know what to do when they get a ‘yes,’ then they’re never going to screen for it,” said Dr. Megan Ranney, an emergency room physician at Rhode Island Hospital in Providence. Ranney helped organize the first continuing medical education course on gun violence, held at the Massachusetts Medical Society this past Saturday.

Ranney says it’s time to clarify the questions doctors should ask patients at risk for domestic violence, homicide, suicide or accidental gun violence, and establish the steps doctors should take to reduce the threat.

Take this example, which Dr. Ron Gross, chief of trauma and emergency surgery at Baystate Medical Center in Springfield, presented to a panel of physicians at the conference.

“A mother with a chief complaint of anxiety shows up in the emergency room,” he said. “She has three kids: 5, 7 and 9. Among the things discussed is her husband’s loaded, unlocked handguns.”

Gross reminded his colleagues that physicians in Massachusetts are required to report cases of suspected child endangerment. So what would they do?

“When I was a kid growing up, a good friend of mine shot and killed his little brother,” said Dr. Kevin Moriarty, a pediatric surgeon at Baystate. “I would consult DCF to get involved.”

But Dr. Eric Fleegler, who works in emergency medicine at Boston Children’s Hospital, would not call the state Department of Children and Families right away.

Fleegler would call in his own hospital social workers first, because, he said, “DCF is more complicated than people appreciate.” Fleegler said it’s hard to tell what DCF will do — remove the children or even make a call to the family.

Pediatrician Sean Palfrey, from Boston Medical Center, would not call the state right away, either, “because that triggers a number of different moves, which might well lose my relationship with the mom.”

None of these doctors is following medical treatment plans as they would with smoking, for example, because such plans don’t exist for guns.

“Trying to convince Americans that their guns are causing a disease is a crude and transparent attempt to ban guns, and Americans won’t tolerate that,” said Wheeler, who urges a focus on educating children about gun safety. “When doctors misuse their patient’s trust to push a political agenda of gun control in the exam room, they’re committing an ethical boundary violation, and that should be illegal.”

But, according to Ranney, of Rhode Island Hospital, discussing gun violence as a medical issue is “not at all about taking guns away from people. It’s about making sure that people who are at risk don’t hurt themselves or others.”

But even for doctors who want to treat guns as a health issue, it’s not clear how to proceed. Dr. Jahan Fahimi, who teaches emergency medicine at the University of California San Francisco, says research shows that patients who have access to guns are two to three times more likely to be successful when they try to kill themselves.

“But what’s missing in this is what physicians should do,” he said. “So we’ve told half the story. We’ve identified that firearms are a major risk factor for suicide completion, but we haven’t yet made it very obvious to physicians what they are supposed to do once they’ve made this identification.”

If the medical community is going to map out those next steps, they should not be the same for all types of gun violence, says David Kennedy, who worked in Boston in an earlier stage of his career, but is now at the John Jay College of Criminal Justice in New York City. Homicide deaths, says Kennedy, are concentrated, often among gangs, in specific neighborhoods.

And yet, “Gun violence often gets treated as if it’s the flu; everybody’s equally exposed, and we can’t predict. It’s not like that, it’s like AIDS. Everybody has sex, except in Boston,” Kennedy added, to laughter, “but very few people are going to get AIDS.”

Some patients are wondering about the inconsistent questions they get from doctors about guns.

Melissa Moore, a mother of three from Topsfield, says her children’s pediatrician always asks about guns in the home. Moore’s husband is a retired police officer. Moore says she and her husband keep the guns and ammunition locked in separate places.

But when Moore sees her own primary care physician, she asks, “Do you have guns in the home?” Moore says “yes,” and leaves it at that, which seems odd to Moore. “Those follow-up questions are really important if you want to treat guns as a public health issue,” she said.

Moore does not think doctors should act to remove guns if they did not feel patients were safe in a home. “I think they would need to do a lot more follow-up before they report a case to authorities. That’s a little too sensitive,” she said.

Mike Weisser, a former gun store owner from Ware, launched the idea for this conference.

“When all is said and done,” Weisser said, “it would be a much healthier discussion if everybody was willing to admit that you are bringing a risk into your home and your life that doesn’t exist if you don’t have a gun.”